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A. gl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ,'NP8 STATE OF CALIFORN WATER RESOURCES CONTR*OARD g°" °RFORMV: u UNDERGROUND STORAGE TANK PROGRAM V_ ❑ 4 GASAHOL ❑ 5 JET FUEL F_� 6 AVIATION GAS E. TANK PERMITI INFORMATION, TANK ® 2 WASTE COMPLETE A SEPARATE FORM WITH THE FOLLOW FORMATION FOR EACH TANK. u D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK_., r6TEMPORARY 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ONE ITEM ® 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT TANK CLOSURE TANK REMOVED ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ®8 100% METHANOL COMPATIBLE FRP PERMIT EXPIRATION DATE MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN _77FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY 41-1 cc FORM 13 (6-29-88) THIS FORM MUST BE ACCOIMP 6 A. OWNERS TANK ID # B. MANUFACTURED BY: ❑ 6 UNLINED 5 UNKNOWN C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ® YES ❑ NO Ile TANK 9ONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. gl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL F_� 6 AVIATION GAS ❑ 5 HAZARDOUS ® 80 EMPTY ❑ 95 UNKNOWN ® 2 WASTE 1:1 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A, 13, C, &D AGENCY # FACILITY ID # A. TYPE OF DOUBLE WALLED F–] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN INERT MATERIAL? YES ® NO SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER PHONE # WITH AREA CODE 1 STEELMON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ® 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ®8 100% METHANOL COMPATIBLE FRP PERMIT EXPIRATION DATE MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN ® 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ® 3 EPDXY LINING ❑ 4 PHENOLIC LINING FORM 13 (6-29-88) THIS FORM MUST BE ACCOIMP 6 C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ® YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ® 2 TAR OR ASPHALT ® AINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE 95 UNKNOWN ❑ 99 OTHER I. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A& 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE !(1?95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTIONSYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK 61 S 2 INVENTORY RECONCILIATION ' P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WAT ONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P � S 95 UNKNOWN P/ s► 99 OTHER VI. INFORMATION A E TLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # SUBSTANCE REMAINING IN INERT MATERIAL? YES ® NO CURRENT LOCAL AGENCY FACILITY AD # GALLONS APPROVED BY NAME COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # 0 �71 [�L CURRENT LOCAL AGENCY FACILITY AD # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT BY: SURCHARGE AMT. FEE CODE *REPT# FORM 13 (6-29-88) THIS FORM MUST BE ACCOIMP 6 FACI'fTY/SITE KATION, ` ', UNLESSENT FORM W HAS SEEN FILED T` PROCESSING Y